Welcome to Youth Leadership Institute (YLI)!

Our Vision:​ ​Youth leading and creating equitable communities

Our Mission:​ ​YLI builds communities where young people and their adult allies come together to create
positive social change. We design and implement community-based programs that provide youth with
leadership skills in a variety of areas, including: prevention, wellness, philanthropy, civic engagement,
youth-media and organizing. ​At Youth Leadership Institute, young people realize their power by learning
to use their voices to create meaningful change​.

Our Values​:​ Inclusion, Innovation, Community, and Social Justice

YLI participants will:

● Develop campaigns to create positive change in your school and/or community

● Lead chapter meetings and trainings
● Have your voice and ideas heard
● Meet new people and have fun
● Develop important leadership skills
● Complete volunteer hours
● Get practical experience that helps you get into college or get a job

Program Description:

The South San Francisco chapter of yli works on issues of tobacco and civic engagement, with a specific focus on
youth empowerment, equity, and social justice. Participants attend City Council meetings, conduct research, and
work on advocacy projects.

Have any Questions or Concerns?

Contact your Program Coordinator or Program Manager with contact information below.

Program Coordinator Contact: Program Manager Contact:

Smitha Gundavajhala Eduardo Gonzalez

sgundavajhala@yli.org egonzalez@yli.org
408-813-5451 760-578-4842

1 - Parents/Guardians - PARTICIPANT PACKET 2019 - 2020

 PARTICIPANT PACKET 2019 - 2020
For YLI Staff Use Only
YLI Program Site (Check box):

☐​ Fresno/Madera ​☐​ Merced ​☐​ San Francisco ​☐ ​San Mateo ​☐ ​Marin

☐ ​Long Beach ​☐ ​Eastern Coachella Valley

Program Name

YLI Program Contact (Adult Ally)

PARENT(S)/GUARDIAN(S) ​(Required information if participant is under 18.)

Name / Relationship
Street Address
City, ST ZIP
Home Phone / Cell Phone
Email
❏ Text message
Contact Preference (please
❏ Phone Call
check all that apply)
❏ Email

Name / Relationship
Street Address
City, ST ZIP
Home Phone / Cell Phone
Email
❏ Text message
Contact Preference (please
❏ Phone Call
check all that apply)
❏ Email

In case I cannot be reached, please contact:

EMERGENCY CONTACTS AND INFORMATION ​(This information will only be used in the event of an emergency.)

Name / relationship

Emergency phone number

Name / relationship

Emergency phone number

Healthcare provider name (if applicable)

Healthcare provider phone (if applicable)

Special medical conditions/ allergies/

medications
2 - Parents/Guardians - PARTICIPANT PACKET 2019 - 2020
Is there something else we should know
about your child and/or family that will
help us best serve them and keep them
safe?

Liability, Media & Medical Release Form (Parent/guardian signature, or self

signature if over 18)
I HEREBY GIVE APPROVAL FOR ____________________________________ (YOUTH NAME) TO PARTICIPATE IN ALL
ACTIVITIES ASSOCIATED WITH YOUTH LEADERSHIP INSTITUTE (YLI). I ASSUME ALL RISKS AND HAZARDS
RELATED TO PARTICIPATION IN THE PROGRAM, INCLUDING TRANSPORTATION TO MEETINGS, OVERNIGHT
RETREATS, MULTI-DAY CONFERENCES/CAMP AND OTHER YLI HOSTED EVENTS.

IN CONSIDERATION OF YOU ACCEPTING MY OR MY CHILD’S APPLICATION, I, THE UNDERSIGNED, HEREBY

AGREE THAT NEITHER I, MY SUCCESSORS, ASSIGNS, NOR ANYONE ACTING ON MY BEHALF WILL MAKE CLAIM
AGAINST OR SUE THE YOUTH LEADERSHIP INSTITUTE (YLI), ITS OFFICERS, AGENTS, EMPLOYEES, OR
VOLUNTEERS FOR INJURY OR DAMAGE RESULTING FROM THE CONDITION OF ANY FACILITY, OR THE
NEGLIGENCE, CARELESSNESS, OR OTHER ACTS, HOWSOEVER CAUSED BY YLI, ITS OFFICERS, AGENTS,
EMPLOYEES, OR VOLUNTEERS FROM ALL CLAIMS OR LAWSUITS THAT I, MY SUCCESSORS, ASSIGNS, OR ANYONE
ACTING ON MY BEHALF MAY NOW HAVE, OR MAY HEREAFTER AT ANY TIME HAVE FOR INJURY OR DAMAGE:
(1) RESULTING FROM THE CONDITION OF ANY IMPROVED FACILITY WHICH HAS BEEN REASONABLY
MAINTAINED; (2) RESULTING FROM THE CONDITION OF ANY UNIMPROVED FACILITY; (3) SUFFERED BY ME
WHILE PARTICIPATING IN OR TRAVELING TO AND FROM THE EVENTS OR ACTIVITIES SET FORTH ABOVE; OR
(4) SUFFERED BY ME IN ANY OTHER ACTIVITY ASSOCIATED WITH THE EVENT OR ACTIVITY AFOREMENTIONED.
THIS RELEASE DOES NOT APPLY TO INTENTIONAL AND/OR WILLFUL ACTS OF MISCONDUCT BY YLI OR ANY OF
ITS OFFICERS, AGENTS, EMPLOYEES OR VOLUNTEERS.

I UNDERSTAND THAT THIS AGREEMENT AND RELEASE OF LIABILITY IS ENFORCEABLE AGAINST ME ONLY, AS
PARENT OR GUARDIAN OF SUCH MINOR, AND THAT SAID AGREEMENT AND RELEASE OF LIABILITY MAY NOT BE
ENFORCED AS AGAINST SUCH MINOR. THEREFORE, IN FURTHER CONSIDERATION FOR PERMITTING SUCH
MINOR TO PARTICIPATE IN THE AFOREMENTIONED ACTIVITIES, I AGREE TO DEFEND YLI ITS OFFICERS,
AGENTS, EMPLOYEES, AND VOLUNTEERS AGAINST ANY CLAIM OR LAWSUIT FOR INJURY, LOSS, OR DAMAGE
ARISING FROM OR IN ANY WAY CONNECTED WITH SUCH MINOR’S PARTICIPATION IN THE EVENT INCLUDING
ANY INJURY, LOSS, OR DAMAGE RESULTING FROM , THE CONDITION OF ANY FACILITY OR FROM THE
NEGLIGENCE, CARELESSNESS, OR OTHER ACTS OF YLI ITS OFFICERS, AGENTS, EMPLOYEES, VOLUNTEERS FROM
ANY LOSS, DAMAGE, LIABILITY, COST OR EXPENSE THEY SUFFER AS A RESULT OF ANY SUCH CLAIM OR
LAWSUIT.

IN THE EVENT, MY SON OR DAUGHTER, A MINOR, BECOMES ILL OR SUSTAINS AN INJURY WHILE IN THE CARE
OR UNDER THE SUPERVISION OF THE YOUTH LEADERSHIP INSTITUTE STAFF, I GIVE MY PERMISSION TO
ADMINISTER FIRST AID TO MY CHILD. IF I, (THE PARENT, THE LEGAL GUARDIAN), CANNOT BE CONTACTED
IMMEDIATELY IN THE EVENT OF AN EMERGENCY, I AUTHORIZE YOUTH LEADERSHIP INSTITUTE STAFF TO
CONSENT TO EMERGENCY HOSPITAL CARE FOR MY CHILD. SHOULD ANY ILLNESS OR ACCIDENT OCCUR TO HIM
OR HER, I WILL NOT HOLD LIABLE THE REPRESENTATIVES OF YOUTH LEADERSHIP INSTITUTE OR ANY OF ITS
STAFF OR PROGRAM INSTRUCTORS. I ASSUME FULL RESPONSIBILITY FOR ALL RELATED MEDICAL COSTS

I UNDERSTAND THAT YLI MAY PHOTOGRAPH OR VIDEOTAPE ME AND/OR MY MINOR CHILDREN AND THAT YLI
MAY USE SUCH PHOTOGRAPHS OR VIDEOTAPES TO PROMOTE PROGRAMS. I EXPRESSLY ALLOW, AND HEREBY
WAIVE ANY OBJECTION TO THE PHOTOGRAPHING AND/OR VIDEOTAPING OF ME AND/OR MY MINOR CHILDREN

3 - Parents/Guardians - PARTICIPANT PACKET 2019 - 2020

WHEN I AND/OR ​MINOR CHILDREN ARE PARTICIPATING IN A YLI PROGRAM. I UNDERSTAND ALL PHOTOS AND
VIDEOTAPES WILL REMAIN IN THE PROPERTY OF YLI.

I ALSO GIVE THE YOUTH LEADERSHIP INSTITUTE STAFF THE RIGHT TO COPYRIGHT AND/OR PUBLISH, REPRODUCE, OR
OTHERWISE USE MY CHILD’S NAME, VOICE, AND LIKENESS AND/OR WRITTEN MATERIAL, PHOTOGRAPHS, AND
AUDIOVISUAL RECORDINGS ABOUT OR BY MY CHILD FOR INSTRUCTION, ART ADVERTISING, PROGRAM WEBSITE,
PUBLICATIONS OR BROCHURES, OR ANY OTHER LAWFUL PURPOSE. I HEREBY AGREE TO RELINQUISH ALL RIGHTS, TITLE
AND INTEREST I MAY HAVE IN THE FINISHED PRODUCT AND WAIVE ALL RIGHTS TO ANY COMPENSATION THEREOF.

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A
RELEASE OF LIABILITY AND INDEMNITY, AND THAT IT IS A LEGALLY BINDING CONTRACT BETWEEN YLI AND ME, AND I
SIGN IT OF MY OWN FREE WILL.

Signature​: ​_______________________________________________ ​Date​: ​__________________

 
 
 
 
 
Thank you for providing the following information to help the Youth Leadership Institute provide a safe,
positive, and effective experience for all YLI participants.
 

4 - Parents/Guardians - PARTICIPANT PACKET 2019 - 2020